When a three-year-old has trouble playing with others and responds to problems by hitting other children, is this cause for concern? What if a small child seems fearful all the time and hesitates to participate in group activities?

When young children seem upset or show disturbing behaviors, it is up to the adults who care for them to figure out the causes and find a way to help. But most child care workers have no training in mental health, and most parents and caregivers lack the knowledge and skills they need to respond to a troubled child.

If parents and caregivers can't solve the problems on their own, early assessment and intervention by a mental health professional can often prevent children's difficulties from worsening. But few families can afford to pay for mental health care, private insurance offers very limited mental health services, and services for low-income families often fall far short of the need (see related article: Medi-Cal: An open door to mental health care for kids).

In recent years, however, some California mental health and child care professionals have developed programs that bring mental health expertise into schools and child care centers and offer timely help to troubled children and their parents.

Mental health: part of healthy development

What does mental health mean in early childhood? It's important to think about mental health in a positive light, as part of healthy child development, says Kadija Johnston, a psychotherapist at the Infant-Parent Program at San Francisco General Hospital. We need to stop defining mental health "by its absence," Johnston says, and focus on helping children build healthy self-esteem and positive relationships.

We can think of mental health as "socioemotional development," says Leonard Levis, director of the West Coast Children's Center in El Cerrito. It's helpful to think of programs that foster mental health as a form of education.

Healthy development includes the child's growing sense of self and capacity to engage in satisfying relationships with others. Young children with good mental health generally experience themselves and the world in a positive way. This does not mean that the children expect all experiences will be happy. But mentally healthy children have enough confidence in themselves and others to believe that problems can be solved.

"A child's experience of self begins to be internalized at a very young age," notes Johnston. Even though a small child's adjustment problems may not always seem significant to adults, it's important not to ignore these difficulties or to assume they will simply go away as the child matures. Very early in life, Johnston observes, "a child develops perceptions of what the world has to offer, and what he or she is able to do in the world. They can only perceive what they have experienced." For example, when children are made to feel their requests are a burden, they may be reluctant to ask for help from adults. If they receive nothing but criticism, they may expect to be treated as "bad children" and behave accordingly.

Interpreting behavior

When we observe a child being unusually withdrawn or starting to "act out" by snatching toys, being overly aggressive, or refusing to cooperate, it is important to consider:

• Temperament — Clinical Psychologist Gabrielle Guedet, who consults for the Child Care Health Program's "warmline," suggests that we first consider the child's usual temperament. Is he or she an active, spirited child or a more subdued one?
  
  
• Culture — What is considered normal in the child's culture at home? A child who is taught that looking directly at an adult is rude, for example, probably won't make eye contact.
  
  
• Age — A two-year-old can't be expected to have the self-control or verbal ability of a child who is five.
  
  
• Circumstances — Does the child have special needs? Has anything unusual happened to the child recently, like a death in the family or a move to a new home?
  
  
• Parental stress — When depression, substance abuse, homelessness, or a life event like divorce incapacitates parents, they often lack the emotional resources to help their children, who may also be in great emotional pain. Some parents also may have problems, like poverty, spousal abuse, or a troubled early life, that add to the stresses of parenting. Helping the child may mean helping the parent too. Unfortunately, resources for mental health care for parents can be even more limited than for children.

The child's viewpoint

Often, Guedet observes, we only pay attention to the behavior as seen by the adult. When we try to understand events from the perspective of the child, we can usually see reasons for the behavior and take action. First, make the child feel accepted and safe. Then work on changing the behavior if necessary.

Cause for Concern?

Psychologist Gabrielle Guedet's rule of thumb is "If you are feeling uncomfortable with something a child is doing, seek assistance." Another basic tip, from therapist Madeline Meyer Riley: when a child has any trouble or upsetting event in her or his life, "there will be an emotional reaction. Assume there will be a reaction and try to support the child through it."

We need to pay close attention when a child:

• Is more fearful and worried than other children
• Has sleeping, eating, or toileting problems
• Displays behavior like hitting, screaming, or fighting on a daily basis
• Treats other children, animals, or objects cruelly or destructively
• Is not talking or expressing needs
• Has trouble forming relationships
• Is unusually quiet, shy, or withdrawn
• Is unable to play
• Has trouble with self-control
• Is hard to soothe or comfort
• Tends to have frequent headaches or stomach aches

This is not a complete list of reasons for concern, and if a child displays some of these signs, that does not necessarily mean the child needs mental health treatment. It's important to view all these issues in light of the child's overall behavior, his or her temperament, and events in the child's life.

Excerpted from materials by the San Francisco General Hospital Infant- Parent Program and the California Child Care Health Program.

How You Are is as Important as What You Do

by Jereee Pawl and Maria St. John

This new 44-page booklet on infant and toddler mental health for people who work with children includes a series of common situations with descriptions of different ways adults might respond. It also includes discussions of important issues and "guiding principles" such as "everyone wants things to be better" and "don't just do something -- stand there and pay attention."

Available for $10 plus $4.50 shipping and handling from Zero to Three, 734 15th Street, NW, Ste 1000, Washington, DC 20005-1013, (800) 899-4301

Extra resources from the Children’s Advocate bulletin (updated 4-08)

• Early Childhood Health Problems and Prevention Strategies: Costs and Benefits, from Partnership for America's Economic Success, finds that at least one in five children has mental health problems that cause at least mild impairment. Also finds that it is cost-effective for society to invest in early childhood health -- specifically, improving mental health and reducing obesity, serious injuries, and exposure to tobacco smoke.

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